Provider Demographics
NPI:1477045268
Name:PETROVICH, KRISTINA
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3405
Mailing Address - Country:US
Mailing Address - Phone:612-351-1529
Mailing Address - Fax:952-285-3980
Practice Address - Street 1:137 FINLEY RD
Practice Address - Street 2:
Practice Address - City:ROSTRAVER TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:15012-1994
Practice Address - Country:US
Practice Address - Phone:724-489-9565
Practice Address - Fax:724-489-9566
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF03740237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty